USS John S. McCain Collision 20 Aug 17

[Colin Parkinson]

Part of the problem in those waters is that any course alteration to avoid another ship can easily put you onto another imminent collision course with yet another ship. Everyone depends on everyone else to follow some sort of rational and consistent course and speed to make it work.

 

[tomahawk6]

The vessel carrying the McCain is being diverted to the PI due to a 4 inch crack that needs to be attended to in a harbor.

https://www.stripes.com/news/pacific/new-hull-crack-typhoon-divert-collision-damaged-uss-mccain-to-philippines-1.493644

 

[Colin Parkinson]

Enough repairs to get her back in service, till a new hull is built and she is stripped of her weapons and sensors?

 

[FJAG]

US Navy Report on McCain and Fitzgerald collisions:

http://s3.amazonaws.com/CHINFO/USS+Fitzgerald+and+USS+John+S+McCain+Collision+Reports.pdf

:cheers:

 

[The Bread Guy]

Bumped with the latest - NTSB report out ...

Insufficient training, severe fatigue and a lack of oversight led to a fatal 2017 Navy collision near Singapore, according to a damning new report from a government agency charged with investigating major accidents.

Officials with the National Transportation Safety Board slammed the Navy for a series of failures that contributed to the August 2017 collision between the destroyer John S. McCain and Alnic MC, a Liberian-flagged oil tanker near the Singapore Strait.

The accident, which tore a 28-foot hole through the McCain's hull below the waterline, was the second of two fatal Navy collisions in the region that summer. Ten McCain sailors were killed in the collision, just months after seven others died when the destroyer Fitzgerald slammed into a container ship off the coast of Japan.

"The NTSB concludes that the Navy failed to provide effective oversight of the John S McCain in the areas of bridge operating procedures, crew training, and fatigue mitigation," the report*, which was released Monday, states ...

* - 57 page PDF

 

[Navy_Pete]

Frustrates me to no end that I've seen detailed public reports on USN, RAN, RN and other navies incidents, but never even saw so much as an executive summary from any of the BOIs that have been done and subsequently buried.  Even Technical and summary investigations are really hard to find, and there is never any real follow up with the results and outcome.  Especially frustrating when you are involved in the incident or possibly responsible for any follow up, as you have no idea what they looked at or what conclusions they came to, and things just tick through the rumour mill instead. The PRO fire and ALG collision are the two most obvious, but there were all kinds of smaller investigations into fuel spills, halon releases etc that get done and tucked away. There was a very high level brief following the PRO incident, but the actual BOI never saw the light of day, so the sequence of events and decision points are things you get second and third hand over a pint.

These reports are a really good learning tool , but forced to learn from other navies due to our culture of secrecy and blame.  There is really no reason why an UNCLASS detailed summary of the sequence of events and findings shouldn't be available (the Westralia report is a great example, as it refers to people by position and spent a lot of time looking at the context leading up to the actual fire that contributed to what happened, as well as what info was actually known to a decision maker at the time they made a call)

Drives me nuts when something is a 'known problem' that re-occurs, but was only ever known to a select few.

 

[Colin Parkinson]

Yes, identifying that a chain of events is forming is a great way to prevent serious accidents. Being able to learn and discuss how previous accidents happen is the best way to avoid future ones.

 

[Navy_Pete]

One really important thing that would be helpful for us to have similar access to RCN specific reports is the impact of SOPs and equipment specific issues.  Our steering control logic as well as the station in control logic is different enough to what is described here that you couldn't replicate some of the same issues. Also their watchkeeping and training structure is different, so harder to compare who is responsible for what. Really weird to me that they transfer the shafts one at a time, and there doesn't seem to be anything preventing someone on the bridge from taking steering back from emergency if they push 'the big red button'.

RN and RAN are both closer, but still enough differences that you can't necessarily draw a straightline in the lessons learned to what we do, and can be tricky to make an apples to apples comparison unless you understand what is similar and where we diverge.  For damage control we all do things slightly differently as well, and it can be pretty specific to the class of ship.

Seems like it was a bit of a dogs breakfast though; suspect we would have been in special sea dutymen to make sure there is a separate helm/throttleman and folks are already back by emergency steering for this specific type of situation, strange that it seems like a bit of an afterthought here (as opposed to planned as part of the nav passage). As well, we put really experienced people in both spots; no way it would have gone to someone with a year in uniform who was going off watch. When nothing happens, seems like overkill, but then something like this happens and in hindsight seems like a prudent approach.

 

[FSTO]

Just finished reading the report. A classic case of a series of small errors that lead to tragic accidents.

- The USN's SSD W&S bill (using a RCN term here) is far too unwieldy. CO, OOD, 2OOD, Conning Officer, Helmsman, Lee Helmsman and Boatswain Mate all having a hand in conning of the ship is a recipe for disaster. Its a no wonder the bridge team lost situational awareness with the confusion of who had steering control and who doesn't.

- The IBNS appears to be a far too complex system for steering and throttle control. Why is there no physical throttles? That would certainly of helped the throttleman notice that he still had 17 knots on the stbd shaft when the order for 10 knots was given. (I haven't been on one of our Frigates for a while. Please tell me that the RCN has retained physical throttles at the steering position.)

This accident was totally avoidable. Hopefully the USN has learned from this and that our leadership at the RCN has hoisted in these LL (at great cost to the USN Sailors who died) as well.

Agree with Navy_Pete complaint that our Navy keeps too much vital information (Cornerbrook grounding?) under lock and key.

 

[dimsum]

Frustrates me to no end that I've seen detailed public reports on USN, RAN, RN and other navies incidents, but never even saw so much as an executive summary from any of the BOIs that have been done and subsequently buried.  Even Technical and summary investigations are really hard to find, and there is never any real follow up with the results and outcome.

Hold on - the RCN doesn't air out that sort of stuff, even from a safety standpoint? 

If the RCAF was involved in a flight safety incident/accident, every single thing would be detailed in the Flight Safety report.  That's not to place blame - it's to make sure that issues are highlighted and hopefully learned...and this is coming from a service with stereotypically big egos. 

 

[FSTO]

Hold on - the RCN doesn't air out that sort of stuff, even from a safety standpoint? 

If the RCAF was involved in a flight safety incident/accident, every single thing would be detailed in the Flight Safety report.  That's not to place blame - it's to make sure that issues are highlighted and hopefully learned...and this is coming from a service with stereotypically big egos.

We have (used to have?) PRONOTES that contains reports of incidents (groundings, collisions, etc) but I don't know where they are located now or if they are even published anymore.

 

[Navy_Pete]

Hold on - the RCN doesn't air out that sort of stuff, even from a safety standpoint? 

If the RCAF was involved in a flight safety incident/accident, every single thing would be detailed in the Flight Safety report.  That's not to place blame - it's to make sure that issues are highlighted and hopefully learned...and this is coming from a service with stereotypically big egos.

Nope, that's one thing I believe the AF does really well.

Generally the technical/summary investigations are UNCLASS, but aren't published or easily available.  The ships used to do biannual tech summaries that would get wide dist, but those went the way of the dodo.  Those were probably the only thing we had that was readily available that you could look through, but quality and reporting of the issue was heavily dependent on how good of a job the writers did (usually a tertiary task that overlapped with the busiest times of the year.

Things like collisions, large fires or floods very quickly get to a board of inquiry, just because of the dollar figures involved. BOI findings get slapped with PRO B/Confidential for no good reason, and get a very restricted distribution.

For example, had a few halon cylinder failures on the ship I was on and the tech investigation was done by the shore facility.  The guy that did it sent me a copy, but otherwise I never would have seen it, and there is nowhere on the DWAN I can go to and look at it, or see if there were similar incidents on other ships with the same cylinders (there were).  That was for something that a bunch of us could have been held personally liable for and fined by Enviro Canada if it was negligence (turned out to be a mechanical failure, so sigh of relief from all of us).  There were a number of similar issues that happened that were also investigated that I never heard anything from, so it's mostly a black hole.

In the same timeline we had an embarked helo for 7 months, and I saw more flight safety reports from our ship and others that were widely disted than I ever did from anything on the Navy side.  Some seemed like they were reinforcing the obvious, but generally seemed like honest reporting of things that helped to remind others what the actual SOP is, or some other possible oddball situations they may have run into.

The BOIs seem to be the BGHs not wanting to air the dirty laundry, but there is really no reason why the TIs and SIs aren't easily available and searchable via the standardized equipment family tree.

 

[Spencer100]

Out with the touch screens in with the steering wheel! 

https://www.engadget.com/2019/08/11/us-navy-drops-touchscreen-controls-for-destroyers/

Not the same as a ship but I like real buttons on my car.  I find the touch screen to slow as you have to look at the screen to change something. 

Plus as someone said video game controllers are buttons and not soft keys so there is a model there.  Video gamers are always looking for the best interface.  I know video games are not warships but humans are controlling both and I think going to "real" controls makes sense to me.  Love to hear what others with real hand experience have to say.

 

[Navy_Pete]

Hard buttons and throttles make a lot of sense from a human engineering perspective.  It lets you do simple things like make the buttons different shapes or give them slightly different textures which is one thing you lose completely with a touch screen.  For something so critical, makes sense to spend the extra few bucks (as long as they don't get those ridiculously flimsy joysticks that they had on the 280s IMCS that had a 1/16" metal pole that would snap if you sneezed in their direction).  Someone will probably complain that you can't instantly punch in a speed and go from full ahead to full astern and may be harder to set increments, but you'll still be far faster then what the actual shafts/pitch are doing, and not rocket science to have a beefy throttle like on a speedboat with fine/coarse modes.

Those stupid screens freeze up all the time anyway, so think it makes sense to have critical inputs like speed and helm with physical wheels and throttles so the console display doesn't result in loss of the station.

Just need to make sure no one does something dumb like hang a jacket off it; can think of a few times off the top of my head where an incorrect button push by someone's jacket, elbow, cup of coffee etc. lead to a drill for steering failure/ console failure.  The new IPMS records every single button push, so that old excuse of 'phantom signal' doesn't really fly.

 

[NavyShooter]

http://halifax.mil.ca/n4nem/n4nem/nem/pages/ftacs/surf/technical_news.html

Once upon a time, I had a link to the Periodic Engineering Letters from the ships, I'll have to see if I can find that again for you.

I agree on the BOI results summary though - there should be some kind of release. 

Also, some PEL's are available online:

http://kms.mil.ca/kms/SearchPage.aspx?KeyWords=PEL

 

[NavyShooter]

Some additional reading:

http://esquimalt.mil.ca/notc/e/Courses/CDC/case_studies_and_pronotes/case_studies_and_pronotes.htm

 

[Navy_Pete]

Thanks!  Don't currently have DWAN access, but some of those old PELs were really helpful.  I hated the ones that were full of reports like 'we did PM and CM on system x', but some of them had all kinds of nuggets about reporting weird issues even if they had no fix. I know we used them a few times for troubleshooting.

I think some poor SLt got tagged with creating a database and trying to look at common issues, but believe they were killed off before that happened.  Was easier with the 280s as you only had two other ships to look at, but still found it good for the CPFs.

Was one of those good ideas that was sometimes poorly executed for individual reports, but found it a helpful tool to get something out there and explain it properly, even if it was already in a UCR or something else, and it was a much better format to include pictures etc with.  Because they had the historical ones, you could go back and pull at a thread if it popped up on a similar ship five or six years ago, and usually chase down what the root cause/fix was.  It was a good way to keep track of those kinds of details that get lost as people are posted/retire.  Remember once doing an at sea line handling winch test to get a provisional certification for using it for RASs back on ATH; was able to pull it up years later and do the same kind of thing (with the appropriate DRMIS notification).  Helped from having to reinvent the wheel.

Did they actually get rescinded?  On a PG, so out of the loop at the moment, but believe that's what I heard.

 

[daftandbarmy]

Those stupid screens freeze up all the time anyway, so think it makes sense to have critical inputs like speed and helm with physical wheels and throttles so the console display doesn't result in loss of the station. especially if your fingers are covered in peanut butter, seawater, or blood and cordite powder

There, FTFY

 

[Navy_Pete]

lol, don't think there is too much cordite or seawater on the bridge.  Have seen cookie crumbs, chip grease and similar on the console buttons.

Read a pretty good book years ago about the technology interface called 'Human Factors' by Kim Vincente.  He's a prof out of U of T, but it's written as a readable novel instead of a textbook.  Uses a bunch of examples, but seems to be something heavily considered in cockpit design. Basically it's about designing the interface so that it works for the user (and not the other way around).  Seems like something they missed but are fixing now.  Link is below in case anyone is curious.

One example was about one of the training planes in WW2.  They kept crashing and when they looked at it, the switch for the landing gear was identical to another one beside it. They did something really simple like put a circle on one and triangle on the other, and went from dozens of crash landings to zero.

Looks like this is something the navy is doing post crash (which is good) but hopefully something we do at the design stage for CSC.  In general, find we get over excited when we can do something with computers where we forget basics like local gauges. Commercial standards are okay for the most part, but sometimes don't get into the weeds, and if you don't specify it somewhere, you probably won't get it. Takes a lot of work to call up standards with additional clarification when you want something above and beyond, so doesn't always happen.

Link to book ; https://www.goodreads.com/book/show/62852.The_Human_Factor

 

[tomahawk6]

The cause seems to be related to a new type of steering system that wasn't fully understood by those who ran it.

https://www.stripes.com/news/us/the-navy-installed-touch-screen-steering-systems-to-save-money-10-sailors-paid-with-their-lives-1.611946